Old neck injury, POTS and nausea while diving

[webjr]

This question realy comes in 2 parts. First, can an old neck injury and low pulse pressure cause nausea and vomiting at the end of a dive during the ascent stage. And 2, Why do doctors always take your BP sitting? I feel like years of problems might have been solved sooner if they had simpley taken my BP standing, Now a little background...
I had a minor neck injury 14 years ago that culminated with a series of spine injections to reduce the symptoms to an acceptable level. Syptoms were the typical numbness in arm and occasional pain and muscle spasms in hand. This was before learning to dive and I've simply learned to accept occasional numbness and pain in the arm. Several years after learning to dive I develpoed a tendency for nausea and vomiting when diving. It was always warm saltwater trips and always towards the end of the dive during ascent. Everyone kept telling me "your just seasick" but I've always felt like there was more to it. No seasick remedies have ever been found to relieve me of this. Fast-forward to this year.... I started having dizzy spells at work, and always when looking straight up or having my head turned at an extreme angle. My arm and hand symptoms have also escalated. Last week I actualy passed out at work and ended up in the hospital. After 3 days of testing and no problem found they finaly decided to let me go home. While they were getting paperwork in order for discharge a new doctor came on shift that had not seen me before and after her asking a few questions she had the nurse do a series of BP tests in different positions. Everytime she tested me standing we got wierd readings.(91/83) Low pulse pressure. I never saw that doctor come back after she ordered these extra BP tests but I think she was on track to finaly discovering the cause of blackout. After allot of reading online I've found this looks allot like Postural orthostatic tachycardia syndrom which lists spine compression as a possible cause and dizziness and nausea as possible symptoms. That may explain my blackout and finaly gets to my question, could this be causing my mysterious "seasickness"? Does my body interpret the drop in pressure ascending as "standing up"? And yes, I'm not diving until all these issues are resolved.:depressed:

 

[tracydr]

First, I think yes, you might have orthostatic hypotension. However, this needs to be investigated much further. There is a test that needs to be done on a tilt table by a neurologist or a nephrologist to determine if this is what is really happening. Or, a simple test called tilts, where blood pressure is done laying down, sitting and standing can be done, even at home, to check this, if you have a blood pressure cough, which you probably should consider getting at this point.
Second, another possibility is that you could have arteries in the back of your neck becoming impinged when you look up and back. This can actually be much more serious and is the cause of strokes during chiropractic adjustments. I urge you to get to the bottom of what's going on. You didn't give us much information to go on-no age or other health issues. A test can be done called an MRI/MRA which is a dye test where dye is injected and you have an MRI of brain and neck to test the arteries at the base of the brain.
I've tried to put this into very basic language for you but this should be enough to ask your doctor for the appropriate testing. Also, the doctor can do some basic physical exams in his office to test for blockage in the arteries in the back of your neck, if he knows how. The chiropractor for sure will know how to do this, if you have a chiropractor.
Finally, did you have an MRI of your neck? With the numbness in your fingers, you should have had some imaging of the neck. If not, you need to have that done to figure out what's going on with the neck to cause the numbness. An EMG to test nerve conduction would also be helpful, to rule out other causes of finger numbness, such as elbow problems or carpal tunnel.

 

[webjr]

Thanks for the reply Tracy, yes they did MRI and MRA with dye both brain and spine and said only thing they found was light errosion of vertebrae (cant recall exact term they used) which they said was maybe a little more than expected for a 53 yr old. They did not do EMG because they said that had to be scheduled through someone else and will be done later this week. They did specificaly look at vertebral arteries also. If there's something in the neck pinching a nerve I don't understand why it wasn't found with MRI or MRA. I know something must be pinched because when hand pain gets bad I can relieve by stretching my neck around. I'm also realy anxious to find out if any of this could be also causing my wierd underwater "seasick" symptoms. I guess the only way I'll know is take a dive trip after they finally find and fix the nerve and BP problems.
Thanks again, Bill
PS
Yes I have a BP tester and have been checking it frequently since I got home from hospital. Systolic always drops and Hystolic goes up standing. Pulse pressure is always < 20 standing and > 40 seated. Last test I ran was 130/76 seated and 114/95 standing. That seems typical so far

 

[DocVikingo]

First, I think yes, you might have orthostatic hypotension. However, this needs to be investigated much further. There is a test that needs to be done on a tilt table by a neurologist or a nephrologist to determine if this is what is really happening.

Hi Dr Tracy,

It is unclear to me why in this case HUTT would be performed by a nephrologist.

Thanks,

DocV

 

[Duke Dive Medicine]

It sounds like there may be multiple factors at work here. I'm sure they would have thought of this in your hospitalization but just so we have all the bases covered: your diastolic pressure goes up with the postural hypotension, which suggests that your peripheral vasomotor response is relatively intact and could help rule out a neurological cause. Are you on diuretics? Are you under a doctor's care for anything else, perhaps a cardiac problem? Did you get a cardiac workup - ECG, ultrasound, or anything else?

You said that the vertigo and nausea happen toward the end of the dive on ascent. Is there a particular place in the water column where it tends to occur? When it happens on the surface, what exactly are you doing? Are you sitting still, or are you moving your head or body?

Best regards,
DDM

 

[webjr]

5ft10 185lbs with no other health problems other than mild high BP controlled on 320mg Diovan (without diuretic). They ran more tests than I can remember ,CT,MRI,MRA and some kind of ultrasound heart video. Only test not done was EMG and I just got appt for EMG test Wednesday morning. One of the last things a doctor at hospital told me was to try cutting back on BP dosage. I've cut dosage in half but BP already climbing too high so I&#8217;m going back to original dose. My weird seasickness is the really weird part. It never happens on shore dives, boat dives only and never on the boat. Only underwater during last 10 minutes of dives during ascent stage. Its happened to frequently I've got pretty proficient at feeding fish under water. These are not extreme dives. Normal recreational vacation dives < 100ft. It happens with almost 100% consistency and only developed a year or 2 after learning to dive. I've tried about everything I can think of to control it with no success. Its been such a problem that I went out of my way this year to book trips with good shore dives. We spent a week at Casino Pt Catalina and another week at Cocoview Roatan. The only time I got sick was the one boat dive I did in Roatan. 15 shoredives at Cocoview without even a rumbling stomach. I feel pretty confident sooner or later they'll figure out my spine and BP problems but it realy drives me nuts to think I may never solve my boating problem. Although after discovering Cocoviews great shorediving I could live with a couple weeks there a year and not miss boats that much.
Thanks again, Bill
Clarification...
No dizzy underwater, I just throw up.
Dizzy has only happened above water when I look straight up or turn my head sharply left. I'm and auto mechanic so I spend allot of time under cars on lifts looking up at the bottom or twisting my head around in confined spaces under dashs.

 

[Duke Dive Medicine]

Did you get the postural hypotension while you were taking the reduced dose of Diovan? If not, you may want to speak to the prescribing practitioner and revisit lowering the dose or explore an alternative antihypertensive medication.

Re the dizziness/nausea: Vertigo that's precipitated by changes in head position is suspicious for benign positional vertigo (BPV):

Benign positional vertigo: MedlinePlus Medical Encyclopedia.

BPV could theoretically be aggravated by the pressure changes under water. Shore dives typically follow a gentler contour for ascents than boat dives, so the pressure changes more gradually on ascent from a shore dive, which would give your ears more time to equalize. Try being very mindful of your equalization on ascent: move your jaw around, do whatever you need to do and exaggerate your clearing efforts (avoid the Valsalva maneuver or anything that adds air to the middle ear space). You may also want to consider a visit to an ENT specialist. Speaking of ENT specialists, we have our own here so hopefully DoctorMike will see this soon and weigh in.

Best regards,
DDM

 

[webjr]

BP reacted about the same on lower dose but symptoms were much less noticeable. I would think that would be normal if its high to begin with and drops when I stand it ends up closer to normal.
re BPV.. This is the first I've heard this idea and definitely worth investigating! Thanks! I do abuse my ears, between chasing students and regular infestations of "swimmers ear". It doesn't sound like it fits my dive profiles but I'll try anything. I'm typically very good at very slow ascents even in open water. I recently made 15 shore dives on Cocoview wall and Newmans wall without issues and these sites both involved vertical ascents from 90ft to 30ft, typical of the same type ascents I'de make on a boat dive. Passing through the 30ft mark seems to be about the time I usually get sick.The very rare occasions when I do have to ascend a little quicker than normal would be a fresh water local shore dive w/3ft vis when I need to grab a student and is usually only a few feet up. I've never been sick under those circumstances. The only common denominator in all this seems to be simply being on a boat but I've never been sick after the Catalina Express ferry. I'm really hoping the nerve problem ties into this somehow. I do know diving affects my neck but I've always looked at it as a positive. Diving pressure always feels like it pushes things back where they need to be and relieves my arm symptoms for awhile. It would be so nice to be able to boat dive again in addition to shore dives.
Thanks for the reply!
Bill

 

[TSandM]

You have so many different things going on here -- hand pain, odd blood pressure readings, and this underwater nausea. They may be related, or they may be completely different.

As far as the nausea underwater goes, that's amenable to some logical analysis. You say it occurs when diving off boats, but never ON the boat, and it does not occur while shore diving. It happens in shallow water, but not during direct ascents in deeper water. Much of this points toward a problem with uneven equalization. Proportional pressure changes are greatest in shallow water, and boat dives involve more direct ascents through that part of the water column than the average shore dive does. But there is another possibility, which is that you are susceptible to motion sickness when required to wait in shallow water -- can you think, do any of these nausea events occur when you have to slow down on the anchor line, or sit in shallow water waiting for other divers to get to the ladder?

As far as your arm and hand pain goes, my first thought when someone reports those symptoms and no investigation of the neck or shoulder reveal a cause, is whether they have cardiac disease. But if you have had these symptoms for 14 years without significant change, that's unlikely. Given the way you describe your work, some type of chronic muscle overuse syndrome might be possible as well -- people can get brachial plexus compression from the scalene muscles, or accessory ribs.

And as for the question of why everybody's BP gets measured seated, it's because the majority of people won't show a significant change between lying, sitting and standing. Only if a patient reports symptoms which are related to postural changes do we measure BPs in multiple positions.

 

[tracydr]

Hi Dr Tracy,

It is unclear to me why in this case HUTT would be performed by a nephrologist.

Thanks,

DocV

Often times, here in AZ, if the generalist doesn't feel comfortable with BP issues, there are some excellent nephrologists who also specialize in BP problems. It can be quite a challenge to find a tilt table so that's why I mentioned it. I remember having to do some digging to find a place to get a service member tested when I was in the Army. She did test positive on the tilt table but we had a heck of a time finding a tilt table. I don't even remember where I sent her. They are becoming much more common but still somewhat difficult to find.